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					                                           North Carolina
                                           State Board of Elections
                                              506 N Harrington Street
                                                Raleigh, NC 27603
Kimberly Westbrook-Strach                                                                       Mailing Address
Deputy Director – Campaign Reporting                                                             PO Box 27255
                                                                                       Raleigh, NC 27611-7255
                                                                                                 (919) 733-7173
                                                                                           Fax: (919) 715-8047


                             Forgiven Loan Statement
This form is used to report a loan that has been forgiven by the lender. The lender’s signature is required
                         on this form and it must accompany the next filed report



Name of Lender:
Committee receiving loan:
Date of loan:
Amount of original loan:
*Amount of loan to be forgiven:

I,                                                      do not wish to be reimbursed
for the amount of the loan indicated above* and will consider the amount loaned a
contribution to the committee.

I understand and confirm no other parties are responsible for payment of this loan. I
may not forgive a loan for which there is an outstanding balance owed to any source.




Signature of Lender



Signature of Committee Treasurer

     Note: This Statement is to be filed with the Election Board where the committee’s reports are filed.




CRO-6200                                  Forgiven Loan Statement                                   June 2007